Citation Nr: 1340668 Decision Date: 12/09/13 Archive Date: 12/20/13 DOCKET NO. 05-29 487 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a bilateral shoulder disorder, to include as due to an undiagnosed illness. 2. Entitlement to service connection for a bilateral finger disorder, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a bilateral hip disorder, to include as due to an undiagnosed illness. 4. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), other than an adjustment disorder with depression. 5. Entitlement to service connection for an acquired right eye disorder, to include as due to an undiagnosed illness, including the question of the finality of any prior rating decision denying service connection for a right eye disorder and whether new and material evidence has been received to reopen any previously denied claim therefore. 6. Entitlement to service connection for an acquired left eye disorder, to include as due to an undiagnosed illness, including the question of the finality of any prior rating decision denying service connection for a left eye disorder and whether new and material evidence has been received to reopen any previously denied claim therefore. 7. Entitlement to an effective date prior to October 31, 2003, for a grant of service connection for degenerative joint disease of the medial compartment of the right knee ("right knee disability"). 8. Entitlement to an effective date prior to October 31, 2003, for a grant of service connection for degenerative joint disease of the medial compartment of the left knee ("left knee disability"). 9. Entitlement to a rating in excess of 20 percent for the right knee disability from March 1, 2004, to April 25, 2004. 10. Entitlement to a rating in excess of 30 percent for the right knee disability and residuals of a total knee arthroplasty on and after June 1, 2005. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and Her Spouse ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from September 1971 to September 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The Veteran presented testimony before the Board in July 2006. The transcript has been associated with the appellate record. In a January 2008 decision, the Board granted entitlement to a higher rating for the Veteran's service-connected mixed tension and vascular headaches and denied ratings in excess of 20 percent for a right knee disorder prior to December 17, 2003, and for a left knee disorder prior to February 22, 2007, as well as a compensable rating for postoperative residuals of excision of a right eye conjunctival cyst. The remaining issues identified on the title pages of the instant decision were remanded so that additional development could be undertaken In an April 2012 decision, the Board denied entitlement to service connection for rheumatoid arthritis and granted an extension of a temporary total rating (TTR) for the right knee disability through February 29, 2004, but not beyond that date, based on the need for additional postsurgical convalescence from a right knee procedure in December 2003 for treatment of the right knee. Again, the remaining issues identified on the title pages of this decision were remanded so that additional development could be undertaken. A corrective order was issued by the Board in June 2012. The case has since been returned to the Board for further review. The issues as to entitlement to service connection for a psychiatric disorder and bilateral eye disorder, as well as the claims for earlier effective dates for grants of service connection for right and left knee disorders, and for a rating in excess of 30 percent for the right knee disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A bilateral shoulder disorder is not shown in service and there is no showing of current disability involving the bilateral shoulders; there is no evidence of a chronic shoulder disability as a result of undiagnosed illness originating during or as a result of service in the Gulf War. 2. A bilateral hip disorder is not shown in service and there is no showing of current disability involving the bilateral hips; there is no evidence of a chronic shoulder disability as a result of undiagnosed illness originating during or as a result of service in the Gulf War. 3. The competent and probative medical evidence of record preponderates against a finding that the Veteran's bilateral finger osteoarthritis is due to events in active service; osteoarthritis of the bilateral fingers is not shown to have been manifested to a compensable degree within one year after the Veteran's separation from service 4. From March 1, 2004, to April 25, 2004, the service-connected right knee disability was productive of functional loss due to pain; however, limitation of extension was not compensable and instability was not shown by the evidence of record. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral shoulder disorder, to include as due to undiagnosed illness, have not been met. 38 U.S.C.A. §§§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.317 (2013). 2. The criteria for service connection for bilateral hip disorder, to include as due to undiagnosed illness, have not been met. 38 U.S.C.A. §§§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.317 (2013). 3. The criteria for service connection for bilateral finger disorder, to include as due to undiagnosed illness, have not been met. 38 U.S.C.A. §§§ 1101, 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.317 (2013). 4. The criteria for an initial 30 percent evaluation, and no higher, between March 1, 2004, and April 25, 2004, for the service-connected right knee disability have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claim pertaining to the right knee arises from the Veteran's disagreement with the initial evaluations assigned following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. With regard to the service connection claims for the bilateral hips, shoulders, and fingers, the RO provided the Veteran pre-adjudication notice by letter dated in April 2004 (including detailed guide on undiagnosed illness claims), June 2004, and April 2005. A notice pursuant to the Dingess decision was sent in March 2006. Additional letters were sent in April 2008 and July 2012. VA also has a duty to assist the Veteran in the development of the claims. VA has obtained service treatment and personnel records, assisted the Veteran in obtaining evidence, provided the Veteran VA examinations, and afforded the Veteran the opportunity to give testimony before the Board, the transcript of which has been obtained. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. II. Analysis A. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §3.303(a). Certain disorders, such as arthritis, are presumed to have been incurred in service if manifested or aggravated within one year of separation from service to a degree of 10 percent or more, provided that the veteran has served a minimum of ninety days either during a period of war or during peacetime service after December 31, 1946. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998) (citing Cuevas v. Principi, 3 Vet. App. 542, 548 (1992)). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Alternatively, the nexus between service and the current disability can be satisfied by medical or lay evidence of continuity of symptomatology and medical evidence of a nexus between the present disability and the symptomatology. See Voerth v. West, 13 Vet. App. 117 (1999); Savage v. Gober, 10 Vet. App. 488, 495 (1997). Under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317, VA shall pay compensation in accordance with chapter 11 of title 38, United States Code, to a Persian Gulf veteran with a qualifying chronic disability that became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016. The term "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of any of the following): (1) A medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms; (2) any diagnosed illness that the Secretary determines warrants a presumption of service connection; (3) an undiagnosed illness in a veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed below, provided that such disability by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. For purposes of this section, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. For the purposes of this section, signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: (1) Fatigue, (2) signs or symptoms involving the skin, (3) headache, (4) muscle pain, (5) joint pain, (6) neurologic signs or symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the respiratory system (upper or lower), (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, 12) abnormal weight loss, or (13) menstrual disorders. Compensation shall not be paid under this section if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. If signs or symptoms are medically attributed to a diagnosed (rather than an undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. See VAOPGCPREC 8-98 (Aug. 3, 1998), 63 Fed. Reg. 56703 (1998); see also Neumann v. West, 14 Vet. App. 12, 22-23 (2000), vacated on other grounds, 14 Vet. App. 304 (2001) (per curiam order). In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. §§ 5107(b), 7104(a); 38 C.F.R. § 3.303(a). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). The record shows that the appellant is a Veteran of the Persian Gulf War, having served in the Southwest Asia Theatre of Operations from February 1991 to April 1991, and, therefore, the initial threshold criterion is met for service connection for the entity claimed under the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 . The Air Force Historical Research Agency has found that it was highly plausible that the Veteran was in the vicinity of hostile military or terrorist activity during her deployment; however, whether she was engaged in combat with the enemy is not determinative of the outcome of the appellate issues herein addressed, as it is noted that 38 U.S.C.A. § 1154(b) (West 2002) does not address the questions of the existence of a present disability or of a nexus between such disability and service, both of which are required for a grant of service connection. Bilateral Hips and Shoulders The Veteran alleges entitlement to service connection for bilateral hip and shoulder disorders, but service treatment records do not identify their presence. Post-service, the Veteran has not been diagnosed with either a right hip or bilateral shoulder disorder. At this juncture, the Board would note that the Veteran indicated in an August 2005 statement that she was not seeking entitlement to service connection on the basis of "Desert Storm illness." Nevertheless, she has not exhibited objective indications of chronic disability of either the hips or shoulders. Shortly after service, the Veteran was afforded a VA examination in January 1992, which was negative for either complaints or diagnoses pertaining to the hips or shoulders. VA examinations in 1998, 2004, 2005, and 2008, as were VA outpatient treatment records and private treatment records, were similarly negative, but for an isolated complaint of shoulder pain in December 2006. The Veteran has testified that her shoulders hurt while she slept, which she is competent to report, but these complaints have not been documented in the medical records and do not establish a chronic shoulder disability. The evidence of record fails to document current hip or shoulder disabilities or an undiagnosed illness involving chronic disability of the hips or shoulders that is attributable to the Veteran's Gulf War service. See Boyer, supra. In the absence of proof of such disability there is no valid claim for service connection. As a preponderance of the evidence is against entitlement to service connection for bilateral hip and shoulder disorders, to include as due to an undiagnosed illness, denial of the benefit sought is required and the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); see generally Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bilateral Fingers The Veteran alleges entitlement to service connection for a bilateral finger disorder, claimed as right middle finger disability. At this juncture, the Board would note that the Veteran indicated in an August 2005 statement that she was not seeking entitlement to service connection on the basis of her Gulf War service. Nevertheless, she has been diagnosed with osteoarthritis of the fingers (a known diagnosis) and thus, presumptive service connection based on such service is precluded. That aside, service treatment records document soft tissue injury to the right middle finger. The mere fact that she was treated for a right middle finger injury is not enough to establish that a chronic finger disability manifested in service. A right finger disease or disability was not shown on the August 1991 separation examination. Shortly after service, the Veteran was afforded a VA examination in January 1992, which was negative for either complaints or diagnoses pertaining to the fingers, as was VA examination in 1998. On a VA medical examination in June 2004, the Veteran described some stiffness in her hands and fingers. The examiner noted that x-rays showed osteoarthritis of multiple fingers bilaterally. Notably, the second, third and fifth distal interphalangeal joints (DIP) on the left hand and second and fifth on the right. There were also osteophytes in the carpometacarpal (CMC) joints bilaterally. The Board would note these findings are clearly outside the one-year presumptive period for arthritis. 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The Board finds that the preponderance of the competent evidence is against a finding of a nexus between the Veteran's finger osteoarthritis and her active service. In that regard, the June 2005 VA examiner opined that osteoarthritis of the fingers was not related to injuries she had in service. The examiner reasoned the injury was many years ago and the Veteran had generalized osteoarthritis changes in both hands. (Emphasis added). As outlined above, the competent medical evidence of record concludes that bilateral finger osteoarthritis is not related to the Veteran's active duty service. The 'chronic disease' was not present to a degree capable of identifying the disease entity during service. No symptoms related to osteoarthritis of the fingers have been identified in the post-service medical record for continuity of symptomatology. The Board concludes that service connection for bilateral finger osteoarthritis is not warranted under 38 C.F.R. § 3.303(b). Moreover, osteoarthritis was not diagnosed to a compensable degree within the year following the Veteran's discharge from active service. 38 C.F.R. § 3.307, 3.309. The only evidence of record to support the Veteran's contentions is her statements. Her statements do not establish a nexus between any acquired pathology and her military service. Although lay evidence is acceptable to prove the occurrence of an injury during active duty or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise. In short, service connection is not warranted on a direct or presumptive basis (to include as due to an undiagnosed illness) for the claimed bilateral finger disorder. The Board finds that the evidence is not in relative equipoise; thus, the Veteran may not be afforded the benefit of the doubt and her claim must be denied. 38 U.S.C.A. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-57. B. Increased Rating Claim for the Right Knee Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath, 1 Vet. App. at 594. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Court has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). Additionally, if the knee condition involves arthritis, the knee disability may be rated under provisions for evaluating arthritis. Arthritis due to trauma is rated as degenerative arthritis according to Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, the disability is to be rated as follows: with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Relevant criteria, under applicable Diagnostic Codes are as follows: A 60 percent evaluation may be assigned for extremely unfavorable ankylosis of a knee in flexion at an angle of 45 degrees or more. A 50 percent evaluation may be assigned for ankylosis of a knee between 20 degrees and 45 degrees. A 40 percent evaluation may be assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 30 percent evaluation may be assigned for ankylosis of a knee at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. 38 C.F.R. § 4.71a; Diagnostic Code 5256. For other knee impairment, recurrent subluxation or lateral instability of the knee, a severe case is to be rated 30 percent disabling; a moderate case is to be rated 20 percent disabling. For a slight case a 10 percent rating is appropriate. 38 C.F.R. § 4.71a, Diagnostic Code 5257. A 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Limitation of flexion of the leg to 60 degrees warrants a 0 percent rating. When flexion is limited to 45 degrees, a 10 percent rating is assigned. A 20 percent rating is appropriate where flexion is limited to 30 degrees. A 30 percent rating is appropriate where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg to 5 degrees warrants a 0 percent rating. When extension is limited to 10 degrees, a 10 percent rating is assigned. A 20 percent rating is appropriate where extension is limited to 15 degrees. A 30 percent rating is appropriate where extension is limited to 20 degrees. A 40 percent rating is appropriate where extension is limited to 30 degrees. A 50 percent rating is appropriate where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Impairment of a tibia and fibula with slight knee or ankle disability may be assigned a 10 percent evaluation. Impairment of a tibia and fibula with moderate knee or ankle disability may be assigned a 20 percent evaluation; impairment of a tibia and fibula with marked knee or ankle disability may be assigned a 30 percent evaluation and nonunion with loose motion requiring a brace or malunion may be assigned a 40 percent evaluation. 38 C.F.R. § 4.71a; Diagnostic Code 5262. According to VA standards, normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. See 38 C.F.R. § 4.71, Plate II (2011). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The VA Office of General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 (degenerative arthritis) does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). See also VAOPGCPREC 9-04 (which finds that separate ratings under Diagnostic Code 5260 for limitation of flexion of the leg and Diagnostic Code 5261 for limitation of extension of the leg may be assigned for disability of the same joint). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Board has reviewed all the evidence in the Veteran's claims file and virtual record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran appealed the May 2004 decision that assigned the initial 20 percent rating for the right knee disability effective October 31, 2003. An evaluation of 100 percent was assigned effective December 17, 2003, based on surgical or other treatment necessitating convalescence. An evaluation of 20 percent was assigned from February 1, 2004. In August 2004, the RO assigned a 100 percent evaluation effective April 26, 2004, based on surgical or other treatment necessitating convalescence. An evaluation of 100 percent was assigned from June 1, 2004. An evaluation of 30 percent was assigned from June 1, 2005. In April 2008, the Board denied entitlement to a rating in excess of 20 percent prior to December 17, 2003. The Board also extended the TTR through February 29, 2004, but not beyond that date, based on the need for additional postsurgical convalescence from a right knee procedure in December 2003 for treatment of the right knee disability. As noted in the Introduction, the Board has remanded the issue of whether a rating in excess of 30 percent is warranted from June 1, 2005. The instant decision shall discuss only whether an initial rating in excess of 20 percent is warranted between March 1, 2004, and April 25, 2004. See Fenderson, supra. As delineated above, the Veteran's service connected right knee was assigned a 20 percent rating under Diagnostic Codes 5010 and 5260 for arthritis, effective between March 1, 2004, and April 25, 2004. In order to afford the Veteran the broadest scope of review, and to ensure that each separate disability involving the knee is evaluated properly, the Board shall consider the service-connected symptomatology involving the right knee under each and every applicable Diagnostic Code that provides rating criteria for evaluating knee disabilities. The pertinent facts found in the medical evidence of record are discussed below. Having carefully considered the Veteran's claim in light of the evidence of record and the applicable laws and regulations, and as outlined in the reasons and bases below, the Board finds that the right knee disability warrants an initial 30 percent rating between March 1, 2004, and April 25, 2004, and no higher, under any Diagnostic Code applicable for rating knee disorders, or any combination thereof. 38 C.F.R. § 4.7. In rating the Veteran's knee disability, the Board notes that under Diagnostic Codes 5003 and 5010, traumatic/degenerative arthritis established by x-ray findings are rated according to limitation of motion for the joint or joints involved. The Board notes that there was radiographic evidence of arthritis of the right knee between March 1, 2004, and April 25, 2004. The criteria for rating extension and flexion of the knee are found at Diagnostic Codes 5260 and 5261, and detailed above. Here, review of the evidence shows that flexion was at worse limited to 80 degrees upon VA examination in April 2004. While the Board is aware that this does not meet the criteria established for a 20 percent rating, or a 30 percent rating for that matter, under Diagnostic Code 5260, the Board is giving the Veteran the benefit of the doubt since the examination was quite limited due to pain following her surgery. The examiner noted the Veteran had recent surgery and was walking with a cane and had an antalgic gait. There was a moderate amount of soft tissue swelling. The Veteran was not able to fully extend the knee. Repetitive testing could not be performed because it was too painful. The examiner found functional impairment was moderately severe to severe. Extension was to 5 degrees upon VA examination in 2004, which does not even meet the criteria established for a compensable rating under Diagnostic Code 5261. 38 C.F.R. § 4.71a. Thus, the criteria do not provide for additional separate rating based on limitation of extension. 38 C.F.R. §§ 4.7, 4.25, 4.71a; See also VAOPGCPREC 23-97 (July 1, 1997, revised July 24, 1997); VAOPGCPREC 9-98 (Aug. 14, 1998); VAOPGCPREC 9-04 (September 17, 2004). The Board has noted the Veteran's complaints of pain experienced in her right knee and thus, considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The complaints of pain and functional impairment due to such pain are the basis for the increase to 30 percent disabling. This is the maximum available under Diagnostic Code 5260. The Veteran's limitation of extension did not meet the criteria for a compensable rating under Diagnostic Code 5261. 38 C.F.R. § 4.71a. Turning next to disability due to instability, the Board finds that the medical records are devoid of objective findings of instability of the right knee between March 1, 2004, and April 25, 2004. On VA examination in 2004, the examiner could not determine any ligamentous laxity in the right knee because it was too tender to test. There was no evidence of recurrent patellar subluxation or dislocation. Accordingly, there is no basis for providing a compensable rating between March 1, 2004, to April 25, 2004, under Diagnostic Code 5257 for recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. The Board has noted the Veteran's complaints of pain experienced in her knee and thus, has once again considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, 38 C.F.R. §§ 4.40 and 4.45, with respect to pain, are inapplicable to ratings under Diagnostic Code 5257 because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 12 (1996). The Board has also considered other potentially applicable diagnostic codes that provide for the assignment of higher evaluations for the Veteran's knee disability. After review, however, the Board observes that no other code provisions can be applied for a higher rating based on the evidence of record. There was no evidence of ankylosis of the knee (Diagnostic Code 5256) or impairment of the tibia and fibula (Diagnostic Code 5262). 38 C.F.R. § 4.71a. As such, based on its review of the medical evidence, the Board finds that an initial 30 percent rating, and no higher, between March 1, 2004, and April 25, 2004, is warranted for right knee pain productive of functional loss and limitation of flexion under Diagnostic Codes 5010 and 5260. A separate rating is not warranted for limitation of extension under Diagnostic Code 5261 or for instability of the right knee under Diagnostic Code 5257. 38 C.F.R. §§ 4.7, 4.25, 4.71a; See also VAOPGCPREC 23-97 (July 1, 1997, revised July 24, 1997); VAOPGCPREC 9-98 (Aug. 14, 1998); VAOPGCPREC 9-04 (September 17, 2004). "Staged" ratings, other than what is already in effect, are not warranted for any period of the appeal. 38 C.F.R. § 4.71a; see Fenderson, supra. The United States Court of Appeals for Veterans Claims (Court) has held that, when evidence of unemployability is presented, the issue of whether a total compensation rating based on individual unemployability (TDIU) will be assigned, should be handled during the determination of the initial disability rating assigned at the time disabilities are determined to be service connected. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). In Rice, the Court determined that there is no freestanding claim for a TDIU rating. Id. at 451. In the instant case, the Veteran has not raised the issue of a TDIU rating with respect to her knee claim for this limited time period. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). The evidence of record shows the Veteran was a employed full-time as a secretary at the time of VA examination in 2004. She informed the examiner that she did not miss work because of her knees as her employer was accommodating. The Veteran made no claims of unemployability during her Board hearing. As the Veteran has not raised such a claim and there is no objective evidence of unemployability due to the service-connected knee disability, a claim for a TDIU rating is not presented in the instant case. The above determinations are based upon application of the pertinent provisions of VA's rating schedule. The Board finds that the record does not reflect that the Veteran's service-connected right knee disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extra- schedular basis. See 38 C.F.R. § 3.321(b)(1) (2010). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). In this case, the Board finds that the rating criteria used to evaluate the Veteran's service-connected right knee reasonably describes her disability level and symptomatology. The criteria allow for ratings based on functional loss (due to such symptoms as pain), limitation of flexion, limitation of extension, and instability of the knee. Diagnostic Codes 5257, 5260, 5261. Given the complaints of pain, the Board awarded a 30 percent rating, even considering that the Veteran did not even meet the criteria for a compensable rating for limitation of flexion or limitation of extension. Instability of the right knee was not shown. Therefore, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Entitlement to service connection for a bilateral shoulder disorder, to include as due to undiagnosed illness, is denied. Entitlement to service connection for a bilateral hip disorder, to include as due to undiagnosed illness, is denied. Entitlement to service connection for a bilateral finger disorder, to include as due to undiagnosed illness, is denied. An initial 30 percent evaluation, and no higher, between March 1, 2004, and April 25, 2004, for the service-connected right knee disability is granted subject to the controlling regulations governing monetary awards. REMAND The Veteran also claims entitlement to service connection for a psychiatric disorder and bilateral eye disorder, as well as for earlier effective dates for grants of service connection for right and left knee disabilities, and for a rating in excess of 30 percent for the right knee disability from June 1, 2005. As noted in the Introduction, these matters were previously before the Board in January 2008 and April 2012. On each occasion, the claims were remanded for further development and adjudication. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268 (1998). As the orders of the Board were not complied with, the matters must be remanded so the Board's instructions can be carried out. By its prior remand, the Board specifically directed the AMC to consider 38 C.F.R. § 3.156(c)(3) in its readjudication of the Veteran's entitlement to earlier effective dates for grants of service connection for right and left knee disabilities. That provision governs questions as to the discovery of additional service department records following entry by VA of a prior adjudication and in this instance it appears that service personnel records were obtained and made a part of the Veteran's VA claims folder (received in January 2004) at a point subsequent to prior denials of service connection for right and left knee disorders in 1992 and 1999. This was again not accomplished on remand, and the Board is thus compelled to remand for corrective action. Stegall, supra. The Board notes as well that, in connection with the Veteran's claim for a rating in excess of 30 percent from June 1, 2005, for the service-connected right knee disability it was requested on remand that the Veteran be afforded a new VA examination. The Veteran was scheduled for a VA examination in June 2013 and failed to appear; however, notice of the examination was sent to the wrong address. The Board must remand for corrective action. Id. The Board notes the Veteran also failed to appear for her psychiatric examination, but notice was also sent to the wrong address. Such examination is imperative in light of the Air Force Historical Research Agency's finding that it was highly plausible that the Veteran was in the vicinity of hostile military or terrorist activity during her deployment. 38 C.F.R. § 3.304(f); Id. Finally, the record reflects that direct service connection was previously denied for defective vision and for hypertropia and a corneal abrasion of the right eye and that service connection for defective vision, secondary to a service-connected excision of a conjunctival cyst, was also the subject of a prior, final denial. The Veteran has since attempted to reopen her previously denied claims for service connection for right and left eye disorders, while concurrently alleging in addition that such are the result of undiagnosed illness incurred during the Gulf War. To date, while the RO and AMC has acknowledged the existence of some, but not all, of the prior denials, questions as to the finality of the prior denials and whether new and material evidence has been received by VA since entry of the most recent denials to reopen the claims have not been adequately addressed to date. Rather, the RO has proceeded without satisfactorily addressing the questions raised by this appeal as to finality of prior claims and the reopening of those claims. Remand to permit the AMC or RO address these questions is necessitated. Accordingly, this portion of the appeal is REMANDED for the following actions: 1. Schedule the Veteran for a VA psychiatric or psychological examination to ascertain whether any acquired psychiatric disorder, including PTSD, is present and its relationship to the Veteran's period of military service. The examiner must be notified that Air Force Historical Research Agency's found it was highly plausible that the Veteran was in the vicinity of hostile military or terrorist activity during her deployment and must determine whether the Veteran's symptoms are related to any such stressor. The Veteran's entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, Veterans Benefits Management System (VBMS), CAPRI, and AMIE) must be available for review by the examiner. If the examiner does not have access to Virtual VA or VBMS, any relevant treatment records in Virtual VA or VBMS that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All indicated tests or studies must be completed. The examiner should then offer an opinion with complete rationale addressing the following question: does the Veteran meet the diagnostic criteria for PTSD, and, if so, is it at least as likely as not (50 percent or greater degree of probability) that the confirmed stressor (the Veteran was in the vicinity of hostile military or terrorist activity) is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to that stressor? The examiner is advised that the term as likely as not does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against service incurrence or causation. More likely and as likely support the contended onset date or causal relationship; less likely weighs against the claim. 2. Afford the Veteran a VA joints examination in order to assess the nature and severity of her right knee disability. The Veteran's entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, Veterans Benefits Management System (VBMS), CAPRI, and AMIE) must be available for review by the examiner. If the examiner does not have access to Virtual VA or VBMS, any relevant treatment records in Virtual VA or VBMS that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All indicated tests or studies must be completed Such examination should include detailed range of motion studies of the right knee and the examiner should determine whether there is any additional functional loss (i.e., additional loss of motion) of the right knee due to pain or flare-ups of pain supported by adequate objective findings, or additional loss of right knee motion due to weakness on movement, excess fatigability, incoordination, or any other relevant symptom or sign. Any additional limitation of motion should be expressed in degrees. The examiner is also directed to express an opinion as to the impact of the Veteran's service-connected right knee disability on her ability to engage in vocational pursuits. 3. Adjudicate the claims to reopen for service connection for right and left eye disorders. Ascertain whether finality has attached to any prior rating actions denying entitlement to service connection for defective vision of each eye, hypertrophia and a corneal abrasion of the right eye, and for defective vision, secondary to a service-connected excision of a conjunctival cyst, and if so, whether new and material evidence has been received by VA with which to reopen any prior final denial. Only those eye disorders for which such a prior final denial is of record should be subject to review on that basis. The claims for all other acquired eye disorders should be treated as original claims, to include but not limited to, eye-related claims based on undiagnosed illness. 4. The AMC is to consider 38 C.F.R. § 3.156(c)(3) in its readjudication of the Veteran's claims of entitlement to earlier effective dates for grants of service connection for right and left knee disabilities. That provision governs questions as to the discovery of additional service department records following entry by VA of a prior adjudication and in this instance it appears that service personnel records were obtained and made a part of the Veteran's VA claims folder (received in January 2004) at a point subsequent to prior denials of service connection for right and left knee disorders in 1992 and 1999. 5. After the development above is completed readjudicate the issues on appeal. 6. If any benefit sought on appeal remains denied, the Veteran and her representative should be provided with a supplemental statement of the case, which should contain notice of all relevant actions taken on the claims for benefits. An appropriate period of time should then be allowed for a response, before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs